Circumcision and HIV: why I'm not convinced.

Cassandra Willyard has a blog post up at The Last Word On Nothing: Why Circumcision Protects Against HIV. Frankly, I am not convinced. Cassandra cites three studies in three different African countries that test the HIV infection rates of circumcised and uncircumcised men. She writes: "In each study, they enrolled between 2,000 and 5,000 HIV-negative men and circumcised half. Taken together, the studies found that circumcision reduced a man's risk of contracting HIV by about 60%." The results are undeniable, but in the comments I cautioned her to avoid extrapolating these results to the relationship between circumcision and HIV in other parts of the world. She responded with "A penis is a penis, no?"

Well, yes. And no. The reason why circumcision is a popular public health initiative to prevent the spread of STDs in African nations is because there are barriers to the use of other, more efficient prophylactics. Condoms are often cited as being from 60-96% effective against the spread of HIV, but condoms are not as easy to obtain in Africa as they are in the USA, for example. In that context, circumcision is an effective way to slow the spread of HIV in African populations. It's certainly better than nothing, but the important thing to remember here is that public health initiatives are highly context-dependent. Should circumcision be promoted as a way of stopping the spread of HIV in the USA? I don't think so, because we have easy access to condoms and sexual education services, which are more efficient at reducing the risk of HIV infection than circumcision. After taking condom use into account, there are very diminishing returns on the benefits of being circumcised.

Additionally, there currently isn't an agreed upon mechanism by which circumcision would provide a physiological barrier to infection with HIV or other STDs. Cassandra does a good job of citing the possible mechanisms, but she also mentions that all of these mechanisms have had mixed results in the literature. I honestly think that there's a very large behavioral component to the risk reduction seen in these African studies. The men in these studies were all circumcised in adulthood, not as infants, and as I said in the comments at Cassandra's post: "The act of having the surgery might influence the sexual practices and behaviors of the men in the study. I imagine that if you have surgery done on your penis, it isn't a stretch to imagine that you'll start using it differently." I would really like to see a study that addresses the effects of the frequency of sex, duration of sex, number of partners, types of sex acts, etc. after having the surgery. I'd also like to see a study that compares HIV infection rates in men circumcised in adulthood with those circumcised in infancy.

In the interest of full disclosure, I need to state that I am morally opposed to circumcision. However, I think the question of morality is irrelevant to this conversation, since policy shouldn't really have anything to do with my morals. My morality isn't the same as your morality, and that's fine. I'm also morally opposed to abortions, but anyone who knows me knows I'm very pro-choice. I am pro-choice when it comes to circumcision too, but I am against it being promoted as a prophylactic in places where there are simply much better options. I think in the USA we have this strange aversion to foreskins as "yucky", which also comes across a little bit in the language Cassandra uses in her post (she refers to foreskins as "weird"). As a society, we engage in normative behavior where circumcised penises are the default and uncircumcised penises are somehow dirtier, "weird", or unpleasant. I find this very problematic.

As an aside, I should really know better than to engage the circumcision crazies on the internet. One day I will learn. I'm not referring to Cassandra here, but rather the type of people who seek out and comment on blog posts about circumcision. They tend to have a special kind of crazy. Perhaps I am one of those people..?

8 comments:

Good post. Circumcision is not just for the crazy. SF is considering banning it, I am sure you know this! I remember thinking about HIV and circumcision a few years back when the studies were coming out. Circumcision and Aids. In addition to the issues you bring up here, it is important to note that the studies don't seem to show any benefit for the receiving partner? There is evidence of a slight increase in transmission to the women having sex with men right after their procedure. I do not think this is a very wise public health intervention.

I thought pro-choice was the choice of the person to decide what happens to THEIR body? The proposed ban on infant circumcision seeks to preserve the right of the male to decide for himself if he wants circumcision. The proposed ban still allows adults to get a circumcision if they want one for their body. I sure wish someone had stopped my parents from having me circumcised when I was a baby.

Here's the way I look at it. Let's say I'm a 22-year-old sexually active male living in Wichita, Kansas, or some such First World locale and I go in for my annual physical. Is my GP going to look at my penis and say, "Oh, I see you're not circumcised. Let's remove that foreskin so you won't get HIV."

That would never happen, right?

So why would you expect an obstetrician or pediatrician in that same locale to say "We should remove this newborn's foreskin so he won't get HIV 22 years from now."?

That's why it bothers me when people try to use the African studies to make a case for RIC in the US. That, and I think the methodology of the studies is questionable.

I agree that the study should have been more specific. Giving the %60 statistic without giving any more details as to the personal lives of the men is just plain unscientific. I find it interesting that you only mentioned two ways of reducing the spread of HIV's, circumcision and condoms, why didn't you mention abstinence? In all of the studies I have read that seems to be the most effective measure.

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I'm Michelle, a newly minted M.Sc. from an ecophysiology lab, and a technical editor for a scientific journal publishing group. Physiologically, I have an overactive sympathetic nervous system. Personally, I am agoraphobic and kind of a nerd. In my free time I blog and drink way too much tea.